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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1078061-Intensive Residential Treatment Services/Residential Crisis Stabilization Investigator(s): Jason Pehler Suspected Maltreatment Reported: It was reported a staff person (SP) drank alcohol during a community outing while providing supervision to vulnerable adults (VA1-VA6), and the SP drove VAs back to the facility after. Date of Incident(s): February 19, 2025 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 17, paragraph (a): The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct. Summary of Findings: Pertinent information was obtained during a site visit conducted on April 17, 2025; from documentation at the facility; and through three interviews conducted with VA2, VA5, and a facility staff person (P). This investigator attempted to contact the SP by mail to request an interview, however, the SP did not respond. VA1 declined to be interviewed by this investigator. VA3, VA4, and VA6 were discharged from the facility prior to the site visit, and were contacted during the investigation, but did not respond to interview requests. Facility documentation showed VA1 was personable, kind, open-minded, and had a strong work ethic. VA1 was diagnosed with depression, post-traumatic stress disorder, and opioid use disorder. VA1’s goals included maintaining sobriety, and finding stable housing. Facility documentation showed VA2 was sociable and maintained healthy interpersonal relationships. VA2’s documentation stated that s/he would “always engage and tell the truth.” VA2 was diagnosed with depression, anxiety, and post-traumatic stress disorder. VA2 had a history of alcohol use, and continued to struggle with alcohol use. VA2’s alcohol use increased his/her mental health symptoms. Facility documentation showed VA3 was hard working, social, and friendly. VA3 enjoyed cooking, and engaged in games and house activities. VA3 was diagnosed with schizoaffective disorder, depression, bipolar affective disorder, and psychosis. Facility documentation showed VA4 enjoyed listening to music and having downtime. VA4 enjoyed socializing with persons s/he was comfortable with, but described him/herself as shy. VA4 was diagnosed with schizophrenia spectrum disorder, depression, and alcohol use disorder. VA4’s mental health symptoms were exacerbated by substance use. Facility documentation showed VA5 presented him/herself as a “happy” person, but preferred social activities with a “limited social circle,” and struggled to identify leisure activities s/he enjoyed. VA5 was diagnosed with schizoaffective disorder and had fears about interacting with other persons. The facility attempted to build trust and provide a supportive environment to VA5. VA5 wanted to maintain his/her environment, and personal hygiene. Facility documentation showed VA6 listened to music, went on daily walks, and watched television. VA6 was diagnosed with schizophrenia spectrum disorder, post-traumatic stress disorder, anxiety, alcohol dependence, and amphetamine type substance use disorder. The facility’s Drug-Free Workplace Policy provided the following: · The facility prohibited employees from “the unlawful manufacture, distribution, possession, sale, purchase or use of illegal drugs, controlled substances or alcohol while on the job.” As well when employees were “working as a representative of the company, on company-owned, -leased, or -controlled property or while operating Company-owned, -leased, or -controlled equipment or vehicles.” · The use of an alcoholic beverage or of another intoxicant on facility’s property, including parking areas, or in the course of company business at any time is prohibited. · Company premises or company property included facilities, vehicles, or offices owned, rented or used by the company including employee owned or rented vehicles while on the property of the company and any other locations where the employee represents the company in any capacity. On February 19, 2025, the SP and VA1-VA6 went bowling as a community outing. There was information obtained that the SP transported VA1-VA6 to and from a bowling alley, however there was also information that a second staff person may have transported one or more of VA1-VA6 to and/or from the bowling alley. During the investigation the facility was unable to find any information which indicated another staff person transported VA1-VA6 to or from the bowling alley. The facility completed an Internal Review which provided the following information: · The facility reviewed a receipt from a community activity on February 19, 2025, and it was discovered the SP paid for an alcohol drink. · The facility completed interviews with VA1-VA5, and the SP. VA6 had left the facility and did not complete an interview. · The SP denied consuming alcohol, and said s/he was not aware an alcoholic drink was purchased. The SP said s/he could have unknowingly purchased an alcohol drink if one of the VAs ordered an alcoholic drink without the SP realizing it. There was no information during the investigation that VA1-VA6 ordered an alcoholic drink. · VA1 did not observe the SP purchase alcohol, but said the SP was “driving recklessly” while returning to the facility from the community outing. · VA2 observed a mug of beer and saw the SP drink the beer. VA2 said that was the only time s/he observed the SP drink alcohol. · VA3 did not observe the SP drink alcohol while at the community activity. · VA4 did not see the SP purchase or drink alcohol during the community outing, but said the SP had previously been “coaxed” into purchasing wings and other things by persons served. · VA5 did not know if the SP purchased the alcohol and did not remember seeing the SP with alcohol. This investigator attempted to or completed interviews with the P, VA1, VA2, and VA5. · The P was not present for the incident, but said s/he had no reason to believe the VA1, VA2, or VA5 would provide inaccurate information. · VA1 declined to be interviewed by this investigator. · VA2 said s/he saw the SP order and drink a beer while at bowling, but another staff person transported VA2 back to the facility. VA2 did not observe any change in the SP’s behavior after drinking the beer. VA2 said there was another incident in which the SP drank a beer while bowling, but was unable to provide a timeframe or any other specifics to that alleged incident. · VA5 said s/he observed the SP drink a beer while on the community activity. VA5 said that was the only time s/he observed the SP drink a beer while working. VA5 did not observe any change in the SP’s behavior after drinking the beer. The P and the SP were trained on Reporting of Maltreatment of Vulnerable Adults Act, the facility’s policies and procedures, and the VA’s client specific programming. Conclusion: A. Maltreatment: It was reported the SP drank alcohol during a community outing with VA1-VA6, and the SP drove the VAs back to the facility after consuming alcohol. VA2 stated another staff person transported him/her back to the facility but the facility did not have any information that there was another staff person driving to or from or at the community outing other than the SP. The facility reviewed a receipt from a community outing which showed an alcohol drink was purchased. The SP was the only staff person present at the community outing and based on the receipt had made the purchase. This investigator attempted to contact the SP to complete an interview, however the SP did not response to the interview request. During the internal review VA2 provided information related to observing the SP consuming the alcohol drink, and VA1 said the SP drove erratically while transporting vulnerable adults back to the facility. The IR stated VA5 did not observe the SP drinking alcohol. VA1 declined to be interviewed by this investigator, however VA2 provided consistent information related to his/her observations of the SP consuming alcohol. Additionally, VA5 said s/he observed the SP drink a “beer” while on the community outing. VA2 provided consistent information to the facility and to this investigator that s/he observed the SP drink alcohol while on the community outing. Although VA5 provided inconsistent information to the facility compared to that which was provided to this investigator, his/her statement to this investigator was consistent with that of VA2’s observations of the SP drinking alcohol while on a community outing. VA1-VA6 had client specific documentation which showed concerns related to mental health diagnoses, and/or prior substance use. Multiple vulnerable adults had alcohol specific diagnosis, and had goals for maintaining sobriety, as well as building trust in a supportive environment. Furthermore, it was noted in the client specific information multiple vulnerable adults present for the alleged incident had increased mental health symptoms due to substance use or alcohol use. Based on the information the SP had purchased alcohol during the community outing, VA2 and VA5 observed the SP drink the alcohol, and VA1 provided information to the facility that the SP drove erratically after leaving the bowling alley. Therefore, it was more likely than not the SP had consumed alcohol and drove a vehicle while providing care and services to vulnerable adults. Additionally, VA1-VA6 were present when the SP drank alcohol, and the majority of those vulnerable adults had goals of sobriety, a history with substance use, and/or mental health symptoms that may be exacerbated by exposure to substances, or required a caregiver to provide a supportive environment. Given that the SP drove the VAs after consuming alcohol and that the SP’s actions subjected the VAs to a risk of harm, there was a preponderance of the evidence that the SP failed to supply the VAs with reasonable and necessary care and services. It was determined that neglect occurred (the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care, or supervision which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult and which is not the result of an accident or therapeutic conduct). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the VA1-VA6’s client specific documentation, the facility’s Drug-Free Workplace policy, and the Reporting of Maltreatment of Vulnerable Adults Act; and was responsible for the care of the VA1-VA6 when the incident occurred. VA2 denied being the vehicle when the SP transported VA1, VA3-VA6 back to the facility. Therefore, the SP was responsible for the maltreatment of the VA1, VA3-VA6. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated neglect for which the SP was responsible did not meet statutory criteria to be determined as recurring or serious. The SP’s behavior was considered a single incident of neglect, and did not result in serious injury. Action Taken by Facility: The facility completed an internal review and determined the facility’s policies and procedures were adequate, but not followed. There was no history of similar events and facility did not complete any additional training. The facility did not complete any additional training or corrective action to protect the persons that received services as the SP was no longer employed by the facility. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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